YMCA Schools Out Registration Form 2021/2022
Participant Information
Childs Name *
School Attending *
Male/Female *
Date of Birth *
MM
/
DD
/
YYYY
Child's Age *
Grade Entering *
DHS # (state pay students only)
Address *
Town *
State *
Zip Code *
Parent 1/Guardian 1 *
Parent 1/Guardian 1 Email
Parent 1/Guardian 1 Cell Phone *
Parent 1/Guardian 1 Place of Work
Parent 1/Guardian 1 Work Phone
Parent 2/Guardian 2
Parent 2/Guardian 2 Email
Parent 2/Guardian 2 Cell Phone
Parent 2/Guardian 2 Place of Work
Parent 2/Guardian 2 Work Phone
Child Resides With *
Emergency Contact Name (Will be included on the "Approved Pick Up List) *
Emergency Contact Cell Phone *
Emergency Contact Home Phone
Emergency Contact Relationship *
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